<html>
<head>
<title>Sistema de Cobranza de Agua</title>
<link href="css/import.css" type="text/css" rel="stylesheet" />
<script language="Javascript" type="text/javascript" src="javascript/functions.js"></script>
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<div id="text-field">

<form method="post" action="#">
<center>
  <table  width="360" border="0">
           <thead>
              <tr>
                <td colspan="2" class="cell-no-search padding-10">Juan Perez</td>
              </tr>
  </thead>
  <tbody>
          	<tr >
	            <td width="190" class="cell-2"><label><span class="formCell">Nombre</span></label></td>
                <td width="208"  class="input-sup"><input class="input-text" name="nombre_empresa" type="text" value="Juan Aberto" /></td>
            </tr>
            
            <tr>
	            <td class="cell-2"><label><span class="formCell">Apellido</span></label></td>
                <td class="input"><input class="input-text" name="codigo_registro" type="text" value="Perez"/></td>
            </tr>
            
            <tr>
	            <td class="cell-2"><span class="formCell">Direcci&oacute;n</span></td>
              <td class="input"><input class="input-text"  name="direccion" type="text" value="Av. Am&eacute;rica E-435 Edificio Jaque Piso 3, Oficina 8"/></td>
            </tr>
            <tr>
	            <td class="cell-2"><span class="formCell">Tel&eacute;fono</span></td>
              <td class="input"><input class="input-text"  name="Telefono" type="text" value="(591-4) 445 0114, (591-4) 412 4128"/></td>
            </tr>
            
            <tr>
	            <td class="cell-2"><span class="formCell">Email</span></td>
              <td class="input"><input  class="input-text" name="logo" type="text" value="correo@gmail.com" /></td>
            </tr>
            <tr>
	            <td class="cell-2"><label><span class="formCell">CI</span></label></td>
	            <td class="input"><input class="input-text"  name="pais"  type="text" value="123123"/></td>
            </tr>
            <tr>
	            <td class="cell-2"><span class="formCell">Municipio</span></td>
              <td class="input"><input  class="input-text" name="departamento_estado" type="text" value="Cochabamba"/></td>
            </tr>
            <tr>
	            <td class="cell-2">Distrito</td>
	            <td class="input"><input class="input-text"  name="municipio" type="text" value="Cochabamba"/></td>
            </tr>
            <tr>
              <td class="cell-2">Coordenadas GPS</td>
              <td class="input"><input class="input-text"  name="coordenada_gps" type="text" value="19,20,21" /></td>
          </tr>
            
            <tr>
              <td class="cell-2">Logo Empresa
              </td>
              <td class="input"><img alt="logo" src="figura.gif" height="25" width="25"></td>
            </tr>
            <tr>
	            <td class="cell-2">Firma Personal</td>
	            <td class="input"><img src="figura.gif" alt="firma" width="25" height="25"></td>
            </tr>
            </tbody>
            <tfoot>
            </tfoot>
    </table>
    </center>
  </form>
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      </body>
      </html>